Improving the cardiovascular health (CVH) of patients and the general population requires increased primordial and primary prevention efforts, according to a scientific statement from the American Heart Association (AHA) published in Circulation.1
Statement authors summarize current evidence in support of a learning healthcare system approach, review contemporary sources for relevant performance and clinical metrics, highlight the role of implementation science strategies, and advocate for an interdisciplinary team approach.
The AHA’s 2020 Impact Goal was developed “to improve the cardiovascular health of all Americans by 20% while reducing deaths from cardiovascular disease and stroke by 20%.” The organization’s Goals and Metric Committee of the Strategic Planning Task Force note: “There is a need to fully implement what is known and for innovative, integrated approaches to optimize CVH in populations and overcome adverse mortality trends.”
In learning healthcare systems, knowledge is consistently generated and applied in the practice of medicine to yield continuous improvements in healthcare delivery, noted the AHA’s writing group. “If population-level CVH interventions are combined with health systems, they can benefit from the operationalization of the learning healthcare system model.”
A synergistic, integrated, and complementary approach using health system–wide resources is needed to implement this model, according to the writing group. The Geisinger Health System and Kaiser Permanente are 2 examples of learning healthcare system models.
Current data streams on CVH metrics include electronic health records, as well as data from mobile and wearable devices. Once validated, data streams can be integrated into current models using advanced data management techniques. Selecting a prioritized set of performance measures is a useful first step to implement and evaluate performance related to CVH, according to the writing group.
“We propose herein a number of evidence-based and actionable population CVH metrics for ongoing monitoring and evaluation of primordial and primary prevention, including maintenance of physical activity, a heart-healthy diet, ideal body mass index, and nonsmoking,” wrote the researchers.
Million Hearts 2022, an initiative from the Centers for Disease Control and Prevention, the Centers for Medicare & Medicaid Services, and other partners, is useful to evaluate population-level CVH initiatives. The primary aim of this initiative is to prevent 1 million heart attacks and strokes within 5 years, but also to align performance measures across federal and partner programs to reduce reporting burden, promote a common target, allow for comparisons across systems, and encourage the use of measures aligned with current guidelines.
“Replication of these activities would be relevant to CVD prevention and management across healthcare settings,” noted the AHA writing group.
The AHA has partnered with the American Medical Association and the American Diabetes Association to improve the diagnosis and management of blood pressure (Target:BP), cholesterol (Check.Change.Control.Cholesterol), and diabetes mellitus (Know Diabetes by Heart). These quality improvement programs aim to support primary prevention of CVD efforts by health systems and healthcare professionals treating patients with important risk factors.
Evidence-based medicine is a cornerstone in modern medicine, and some evidence-generating activities are more advanced than others, notes the AHA writing group. “Epidemiologists and other researchers have the skills to help define which outcomes of medical interventions are relevant and how to measure them effectively and efficiently. They can assist healthcare systems in designing, monitoring, and evaluating efforts to improve population CVH.”
Implementation science offers rigorous metrics for designing and evaluating clinical research questions. “Implementation science research seeks to understand what is required, in terms of feasibility, time, and cost, to facilitate the adoption, uptake, and sustainability of an intervention in clinical settings,” stated the writing group. “Learning healthcare systems are informed by quality improvement efforts and are implemented, or de-implemented, according to best practices in implementation science.”
De-implementation — or reducing or stopping the use of ineffective, harmful, low-value, or unproven interventions, practices, and programs — is especially important for population CVH interventions, according to the writing group.
The expertise of diverse team members is necessary to ensure that population CVH interventions are acceptable to patients, healthcare professionals, health system administrators, and information technology staff before implementation.
“Researchers and healthcare professionals are essential components of a comprehensive strategy to improve CVH,” the AHA writing group commented. “Through their complementary expertise, they can provide direct patient care, implement new guidelines into management, track metrics and evaluate them over time, test novel strategies with the potential to improve CVH, and implement strategies to prevent the onset of chronic disease.”
Developing, deploying, and evaluating interventions to improve population CVH requires a system-wide, interdisciplinary approach. “Although the healthcare team does not typically include an epidemiologist, epidemiologists are uniquely positioned to contribute to health and the deployment of learning healthcare system models,” noted the statement authors. Biostatisticians and data scientists also play a key role in data management and analysis.
“We believe that early and frequent consultation between interdisciplinary teams and members of the healthcare ecosystem bode success for population CVH management strategies,” the writing group commented.
Examples of successful CVH and prevention programs in healthcare systems include the SPHERE (Stroke Prevention in Healthcare Delivery Environments) study and Priorities Wizard, which are clinical decision support (CDS) tools.2, 3
The SPHERE study aimed to enhance communication between patients and healthcare professionals regarding CVH and to improve the delivery of preventive cardiovascular care in the primary care setting. Use of the SPHERE tool vs control clinic led to 1-year improvement in body mass index and diabetes mellitus.
The use of Priorities Wizard, a web-based CDS tool, was associated with significant improvement in high-burden cardiometabolic metrics in 3 large integrated health systems. Use of the tool was associated with improvements in glucose and blood pressure control in patients with diabetes mellitus, reductions in the 10-year CVD risk in high-risk adults without diabetes mellitus, improved management of smoking in dental patients, and improved identification and management of high blood pressure in adolescents.
According to the AHA writing group, healthcare systems should seek to meet the increasing demand for data-driven intervention strategies and risk algorithms to optimize population CVH.
“Interdisciplinary teams have the tools needed to effectively integrate population CVH interventions into the healthcare ecosystem and ensure that meaningful metrics and outcomes are being evaluated with the end goal of primordial and primary prevention of CVD,” noted the authors.
CVH interventions should be applied equitably across various settings and populations, and evidence-based implementation science tools and techniques can aid interventions seeking to improve population CVH and enhance and preserve health equity.
“To achieve that end, a prioritized set of CVH performance measures, particularly those commonly collected in the electronic health record and consistent with other national initiatives such as Million Hearts, will facilitate dissemination of successful interventions across healthcare systems,” wrote the AHA writing group. “Scaling evidence-based interventions across healthcare systems has the potential to maximize the population CVH impact of such approaches.”
- Foraker RE, Benziger CP, DeBarmore BM, et al; on behalf of the American Heart Association Council on Epidemiology and Prevention; Council on Arteriosclerosis, Thrombosis and Vascular Biology; and Council on Lifestyle and Cardiometabolic Health. Achieving optimal population cardiovascular health requires an interdisciplinary team and a learning healthcare system: A scientific statement from the American Heart Association [published online December 3, 2020]. Circulation. doi: 10.1161/ CIR.0000000000000913
- Foraker RE, Shoben AB, Kelley MM, et al. Electronic health record-based assessment of cardiovascular health: The Stroke Prevention in Healthcare Delivery Environments (SPHERE) study. Prev Med Rep. 2016;4:303-308.
- Sperl-Hillen JM, Rossom RC, Kharbanda EO, et al. Priorities Wizard: Multisite web-based primary care clinical decision support improved chronic care outcomes with high use rates and high clinician satisfaction rates. EGEMS (Wash DC). 2019;7(1):9.